Intake Form - Michigan

Nathan G. Frazier
Attorney & Counselor at Law
516 W WASHINGTON, ANN ARBOR, MI 48103
CALL: (734) 619-6980

Confidential Intake Questionnaire. Thank you for choosing to reserve a consultation with us. I look forward to meeting with you to discuss your legal issues in depth. Your submission will be securely encrypted, sent directly to me and is legally protected by attorney-client privilege.

How long will it take me to complete this form? 30-45 minutes.
How Did You Find Us? *

Washtenaw County Bar Referral Hyatt Legal Plans ARAG Legal Plans Google (via search and/or Google Maps) From a friend
Legal Plan Information
ARAG confirmation number (provided to you by ARAG's Customer Care Center at 866-272-4529)?
What is Your Relation to the Legal Plan Member?

I am a Member I am a Spouse of a member I am a Dependent of the member
Member's Name?

First Name Last Name

What is the Members' Social Security Number? (We need this to verify coverage.) *
Your Legal Issues
What Do You Wish to Discuss at Your Consultation? *

I am married with children and I want to discuss a divorce or separation. I am married with NO children and I want to discuss a divorce or separation. I just want to discuss a custody or child support issue. I want to discuss an immigration issue. I want to discuss an adoption. Other.

Insurance
Health Insurance Information
Who Has Health Insurance?

You Your Spouse / Opposing Party Your Child(ren) None
What is Your Insurance Company's Name?
Other Than You, Anyone Else Covered By This Policy?
Cost Per Month?
Cost of COBRA (if known)?
What is Your Spouse / Opposing Party's Insurance?
Anyone Else Covered By This Policy?
Cost Per Month?
What is Your Child(ren) Insurance Company's Name?
Anyone Else Covered By This Policy?
Cost Per Month?
Do You Have Term or Whole Life Insurance?

Yes No
Which Company and Term or Whole Life?
Cash Surrender Value?
Premium?
Does Your Spouse Have Term or Whole Life Insurance?

Yes No
Which Company and Term or Whole Life?
Cash Surrender Value?
Premium?

Adoption Information
Adoption
How Many Children are You Hoping to Adopt?
Child 1 Name

First Name Last Name
Child 1 Birthdate

- Month - Day Year
Child 1 is current staying with:
Child 2 Name

First Name Last Name
Child 2 Birthdate

- Month - Day Year
Child 3 Name

First Name Last Name
Child 3 Birthdate

- Month - Day Year
Child 4 Name

First Name Last Name
Child 4 Birthdate

- Month - Day Year
Child 5 Name

First Name Last Name
Child 5 Birthdate

- Month - Day Year
What is the full name of the biological mother of the child(ren) to be adopted?

First Name Last Name

Will the biological mother will agree to the adoption?

Yes No Unsure
What is the full name of the biological father of the child(ren) to be adopted?

First Name Last Name

Do you think the biological father will agree to the adoption?

Yes No Unsure
Tell me why you are looking to adopt and any other important information I should know:

Final Questions RE Fee Agreement and Truthfulness
No Representation Unless Fee Agreement is Signed
I am seeking a consultation only and understand that Attorney Nathan G. Frazier will not represent me until we both sign a written fee agreement. *

No, I do not understand or agree. Yes, I understand and agree that there is no continuing legal representation until we both sign a fee agreement.
Statement of Truthfulness
By clicking submit below, I certify that I have read and understood the instructions above and that the information I provided is true and correct to the best of my knowledge and belief. *

Legal Plan Information